What are the treatment guidelines for a patient with asthma exacerbation no longer responding to albuterol (beta-2 adrenergic receptor agonist) or their maintenance inhaler, and should a chest x-ray be repeated?

Management of Asthma Exacerbation Unresponsive to Initial Therapy

For patients with asthma exacerbation not responding to albuterol or maintenance inhaler, immediate escalation to systemic corticosteroids, ipratropium bromide, and consideration for hospital admission is necessary, along with a chest X-ray to rule out complications such as pneumothorax, consolidation, or pulmonary edema. 1, 2

Initial Assessment and Management

• Recognize features of severe asthma exacerbation: inability to complete sentences, respiratory rate >25 breaths/min, peak expiratory flow (PEF) <50% of predicted/best, heart rate >110 beats/min 1
• Life-threatening features include: PEF <33% of predicted/best, silent chest, cyanosis, feeble respiratory effort, exhaustion, confusion, or altered mental status 1, 3
• Administer high-flow oxygen to maintain oxygen saturation >90% (>95% in pregnant patients or those with heart disease) 1, 4
• Continue high-dose inhaled beta-agonists: salbutamol 5 mg or terbutaline 10 mg via nebulizer with oxygen or multiple actuations of MDI with spacer (4-12 puffs) every 20 minutes for 3 doses 2, 1

Escalation of Treatment

• Add ipratropium bromide 0.5 mg nebulized to the beta-agonist therapy, which has been shown to increase bronchodilation and reduce hospitalizations in patients with severe exacerbations 1, 3
• Administer systemic corticosteroids immediately: prednisolone 30-60 mg orally or intravenous hydrocortisone 200 mg 2, 1
• Consider intravenous magnesium sulfate (2g IV over 20 minutes) for patients with severe refractory asthma 1, 4
• If no improvement after 15-30 minutes, give nebulized beta-agonists more frequently (up to every 15 minutes) 2
• For continued poor response, consider intravenous aminophylline (250 mg over 20 minutes) or intravenous salbutamol/terbutaline (250 μg over 10 minutes) - do not give bolus aminophylline to patients already taking oral theophyllines 2

Diagnostic Imaging

• A chest X-ray is indicated in this case to exclude complications such as pneumothorax, consolidation, or pulmonary edema 2, 1
• Despite the previous X-ray being 9 months ago, a new chest X-ray is necessary during an exacerbation unresponsive to initial therapy to rule out complications or alternative diagnoses 2
• Additional investigations should include measurement of plasma electrolytes, urea concentrations, blood count, and in older patients, electrocardiography 2

Monitoring and Reassessment

• Measure and record PEF 15-30 minutes after starting treatment and thereafter according to response 2
• Monitor oxygen saturation continuously until a clear response to bronchodilator therapy has occurred 1, 4
• Reassess the patient 15-30 minutes after starting treatment, measuring PEF or FEV₁, and assessing symptoms and vital signs 1
• Response to treatment is a better predictor of hospitalization need than initial severity 1, 5

Criteria for Hospital Admission

• Any life-threatening features or features of a severe attack that persist after initial treatment 2
• PEF 15-30 minutes after nebulization <33% of predicted or best value 2
• Deteriorating PEF, worsening or persisting hypoxia despite oxygen therapy, or hypercapnia 2
• Onset of exhaustion, feeble respiration, confusion, or drowsiness 2, 3
• Consider a lower threshold for admission in patients seen in the evening, with recent onset of nocturnal symptoms, previous severe attacks, or concerning social circumstances 2

New Treatment Options to Consider

• For future management, consider albuterol-budesonide fixed-dose combination as rescue medication, which has been shown to reduce the risk of severe asthma exacerbations by 26% compared to albuterol alone in patients with uncontrolled moderate-to-severe asthma 6
• This combination approach can decrease asthma exacerbations and oral corticosteroid burden in patients with moderate-to-severe asthma 7

Discharge Planning (After Stabilization)

• Patients should not be discharged until symptoms have stabilized or returned to normal function 2
• PEF should be above 75% of predicted value or best level, with diurnal variability below 25% 2
• Ensure patient has appropriate maintenance therapy and written self-management plan 2
• Arrange follow-up with primary care within 1 week and specialist clinic within 4 weeks 2

Common Pitfalls to Avoid

• Underestimating severity of asthma exacerbation - always make objective measurements 1
• Delaying administration of systemic corticosteroids, which should be given early in the course of treatment 1, 5
• Administering sedatives of any kind, which are contraindicated in acute asthma 1
• Giving antibiotics unless there is clear evidence of bacterial infection 1, 5
• Relying on blood gas measurements alone for children, which are rarely helpful in deciding initial management 1